Introduction
The following review will discuss the issue of service user involvement in the discharge/transfer procedure. The review was compiled by the author within a nineteen bedded Forensic Mental Health unit. The ward was at full capacity at the time of writing this review.
The service users’ all had different levels of mental illness, each with a different history, level of cognitive awareness, degree of institutionalisation and willingness to adapt and change. This review will assess to what extent service users are involved with the care planning/discharge planning process in the ward and give possible recommendations on how this process may be improved.
The review will consist of an introduction, aims of the review, methods of data collection, findings on a series of questions and answers on the extent of service user involvement in the discharge process, conclusions, and possible recommendations for change. It will conclude with a reflection piece. 148
Aims of The Review
During this placement the author decided on a subject to review, this subject was service user involvement in discharge planning. While collating information for the review some questions arose these questions were:
Does the service user feel included in decision making?
How does the staff involve the service user in the decision making if at all?
Has discharge been discussed with the service user?
These questions lead to the author constructing some key questions to carry out in the review these will be discussed further in the findings. 91
Methods used to Construct review
The data for the review was collected over a ten week period within the ward. The author consulted service users’ notes, attended multidisciplinary team meetings and conducted a series of semi-structured, one to one interviews with service users and staff, including a consultant, doctors, ward manager, nurses, nursing assistants and occupational therapists.
A literature search was also carried out using accredited databases including CINAHL and the British Nursing Index. Relevant journal articles were found on these databases using keywords such as service user, involvement and mental health services. Nursing research books were also used to gather information along with web sites underlining national policies and models for mental health nursing. 110
Findings
How are decisions made within the placement area regarding discharge planning?
Throughout the weeks on this placement research was carried out by the author on policies and procedures for discharge planning. The one in particular that was found to be relevant was the Care Programme Approach (CPA). CPA is about early identification of needs, assignment of individuals or organisations to meet those needs in an agreed and co-ordinated way and regular reviews of progress with the patient and care providers. CPA is also about involving family or carers at the earliest point. The Care Programme Approach requires that patients should be provided with copies of their care plans and it has been increasingly common for patients who have been the responsibility of forensic psychiatrists to have copies of documents relating to their care. (DOH 2008).
Systems were in place for comprehensive care planning. There was evidence to show that the service users’ social, educational and occupational needs were taken into account in the care planning process and other specialist interventions were available.
In addition to this, in some cases, discharge planning was evident from an early stage (not long after admission), although in other cases a few months had elapsed before any document noted those discussions. Discharge planning is enhanced by the Care Programme Approach (CPA) a multi-disciplinary care planning systematic approach that involves service users and their carers’. Care Programme Approach is the framework for care co-ordination and resource allocation in mental health services. Decisions for discharge are made through the multi-disciplinary team which consists of consultants, ward manager, nursing staff, occupational therapy and social workers. This will go forward to a tribunal where the service user will be invited to take part, here all the evidence will be put forward and a decision will be made. If the service user is restricted then the decision will be made by the First Minister.
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Most service users have long term mental health problems and complex social needs and have been in contact with mental health services for more than twenty years so never think about discharge. Being in hospital for so long has become part of their lives so service users see it as pointless being discharged, “what would I do” 360
What decisions/involvement does the service user have in this process?
Service users’ are encouraged to be fully involved in all aspects of their care as far as they are able to. Service users past and present wishes should be taken into account, their views and opinions with regards to their treatment plan must also be recorded, as stated in the Mental Health (Care and Treatment) Act 2003. The principles of the act underpin any decision made relating to a detained service user in Scotland. The Milan Committee devoted a chapter in the act that referred to high risk patients it stated that service users should have the right of appeal to be transferred from a high or medium secure facility to that of a facility with lower security conditions. (Mental Health Care and Treatment Scotland Act 2003).
Within this placement care and treatment plans are reviewed on a regular basis. Service users are expected to meet with their key worker and other team members on a regular basis, care plans are reviewed at these meetings and a mutual agreement will be decided, on the best way forward, once the care plan has been agreed by all the service user has to adhere to the care plan.
Service users have the opportunity for regular one-to-ones with their key workers (weekly basis) or more regularly if they require. Service users have the opportunity to put forward their thoughts on discharge and any other aspect of their care at the review, such as their rights beliefs and their right to a tribunal (The Human Rights Act 1998).The review takes place every four months, again this is a multi-disciplinary meeting and service users are invited to attend with the support of advocacy or someone of their choice. The Human Rights Act 1998 gives legal effect in the UK to certain fundamental rights and freedoms contained in the European Convention on Human Rights (ECHR). These rights not only affect matters of life and death like freedom from torture and killing, but also affect your rights in everyday life: what you can say and do, your beliefs, your right to a fair trial and many other similar basic entitlements.
During the time spent on this placement it was noted that service users and key workers met at the beginning of the week to discuss how they felt things have been for them, the service user has the opportunity to discuss what changes they would like to happen, this is then recorded in the service users’ notes and taken forward to the clinical team that week where it would be discussed if any changes in care and treatment would take place, the service user is then informed of any changes and decisions made. The opportunity arose for the author to take part in these weekly reviews, during this one-to-one time most service users were able to express their thoughts and feelings about issues they had encountered that week and describe what therapeutic strategies they used to get through it.
The service user will be provided with a copy of the Treatment Plan Objectives, or informed in detail of the contents of the treatment plan, in the event that any learning or specific reading or language difficulty information should be provided in a way that is most likely to be understood.
Arnstein (1969) constructed a “ladder of participation” which described eight stages of user participation in services, including mental health. These stages ranged from no participation to user controlled services. The above service users would be placed on the sixth rung of the ladder in the partnership range as they agree to share planning and decision-making responsibilities.
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Does this placement area reflect it’s practice on local or national policies regarding service user involvement in discharge planning?
When asked their views on the subject the Ward manager and senior nursing staff presented documentation which reaffirmed current practice within the ward. The Ten Essential Shared Capabilities (ESC’s,) he explained was the model now being followed on the ward, has just been implemented into this area of placement within the last two years, which the ward staff have adopted well by providing a person-centred approach as much as possible. This new person-centred model embraced the ethos of the above, and senior staff stressed that good practice dictated that service users have the opportunity to appropriately influence delivery of care and support. A review of policies and procedures as well as discussions with staff provided evidence that the policies were actually in place.
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Throughout the placement, the author noticed that efforts were being made all the time to nurse according to the new model. Included were regular one to one sessions between nurses and service users to hear their views and thoughts, these already took place before the ESC’s were introduced. Moreover some staff do find it difficult to adopt the ESC’s and the mental health act due to the restraints of the environment (secure ward), however they are prepared to embrace the opportunity for further education and support.
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Identify barriers and constraints.
While on placement and conducting this review the author noted that one of the barriers to effective involvement came from some of the service users, due to the complex nature of the area the service users had become institutionalised and found it difficult to be thinking about discharge at this stage in their lives, so they just accept the way things are and do not get too much involved as far as care plans are involved and just say what they think the staff want to hear.
In secure settings engagement of service users in assessment and treatment can be difficult, as there is a potential risk of perceived coercion.
Moreover with the lack of medium secure facilities around this can hinder service users from moving on within the specified time limit agreed, as there are no provisions.
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Recommendations for Development
Most service users were more concerned about their futures and life post discharge. They wanted their time between now and then to be concerned with preparing them for discharge. It was frustrating for many service users that they felt that little in the way of such preparation was taking place
High secure units should ensure that at the point of discharge patients have a copy of their discharge care plan in a suitable format which includes appropriate information about the circumstances that might result in their return to secure mental health provision.
However a recommendation that high secure units should ensure that factors to be weighed in assessing relapse are part of the risk assessment included in the discharge plan of all patients.
The National Service Framework for Mental Health states that ‘Service users and carers should be involved in planning, providing and evaluating training for all health care professionals’ (Department of Health, 1999). This is the case in most health care provisions but for more education, training and information to be more readily available.
Strengthening the user perspective and user involvement in mental health services has been a key part of policymaking in many countries, and also has been encouraged by World Health Organization (WHO) in order to establish services that are better tailored to people’s needs and used more appropriately.
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Reflection
In this review, I need to reflect on the situation that took place during my clinical placement to develop and utilise my interpersonal skills in order to maintain the therapeutic relationships with service users. In this reflection, I am going to use Gibbs (1988) Reflective Cycle. This model is a recognised framework for my reflection. Gibbs (1988) consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future.
During the first week of placement I was encouraged to work closely with my mentor. This gave me the opportunity to orientate myself to the ward and get an overview of the needs and requirements of the service users. This also provided me with the chance to observe how the nursing team worked on the ward. During this time I have learned that if the concept of interprofessional working is to succeed in practice, professionals need excellent team working and communication skills. Good communication, as we have staged in our group work theory, is crucial in the effective delivery of patient care and poor communication can result in increased risk to the service users. I have learned the valuable skills required for good communication and will transfer these into practice by adapting to the local communication procedures. The NMC advices that at the point of registration students should have the necessary skills to communicate effectively with colleagues and other departments to improve patience care (NMC, 2004).
In conclusion of my reflective assignment, I mention the model that I chose, Gibbs Reflective Cycle(1988) as my framework for my reflective piece. I state the reasons why I am choosing the model as well as some discussion on the important of doing reflection in nursing practice. I am able to discuss every stage in the Gibbs (1988) Reflective Cycle about my ability to develop my therapeutic relationship by using my interpersonal skills with service users for this reflection. 369
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